NPIMap

Organization Active NPI

Fast Pace Medical Clinic PLLC

  • Rural Health Clinic/Center
  • Camden, TN
National Provider Identifier
1467117804
Registry record updated Nov 1, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
FAST PACE MEDICAL CLINIC PLLC
Practice address
284 Highway 641 N
Camden, TN 38320-1350
Phone
(731) 213-2446
Fax
(731) 213-2447
NPI assigned
Nov 1, 2021
Last updated
Nov 1, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 1, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert Benson
Title
Coo
Phone
(931) 253-1110

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

284 Highway 641 N
Camden, TN 38320-1350

Mailing address

PO Box 306244
Nashville, TN 37230-6244

Other identifiers 1

IdentifierTypeStateIssuer
1515574MedicaidTN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211229002460 TN Part A Provider - Rural Health Clinic 5395881841 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Camden, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1467117804. Details of each certification follow.

Rural health clinic certification: CCN 883866

Legal name
FAST PACE MEDICAL CLINIC PLLC
Doing business as
FAST PACE HEALTH
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 1, 2022
Last certification
Feb 1, 2022
Ownership / control type
1A
Organization structure
OtherProprietary
Incorporated
Oct 5, 2009 in TN
Enrollment address
284 Highway 641 N
Ste 225
Camden, TN 38320-1350

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Selena Michelle Gurley Individual 5% Or Greater Direct Ownership Interest May 10, 2019 33.33%
Sydni Clemmons Individual Corporate DirectorDirector of Credentialing Nov 1, 2021
W-2 Managing Employee Nov 1, 2021
Karen Denise Daingerfield Individual 5% Or Greater Direct Ownership Interest May 10, 2019 33.33%
Fpmcm, LLC Organization, Franklin, TN LLC Operational/Managerial Control Oct 5, 2009 100%
Dana Kay Martin Individual 5% Or Greater Direct Ownership Interest May 10, 2019 33.33%

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1635724800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635724800000",
    "number": "1467117804",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 306244",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372306244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "284 HIGHWAY 641 N",
            "city": "CAMDEN",
            "state": "TN",
            "postal_code": "383201350",
            "telephone_number": "731-213-2446",
            "fax_number": "731-213-2447"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAST PACE MEDICAL CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-01",
        "last_updated": "2021-11-01",
        "certification_date": "2021-11-01",
        "status": "A",
        "authorized_official_last_name": "BENSON",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "931-253-1110"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1515574",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Camden, TN

Sources for this page

Verify at the official NPI Registry.